Constitutional Treatment of Chronic Pelvic Diseases-C. D. Palmer, Cincinnati,

Congenital Joint Deficiencies-C. H. Muschlitz, Philadelphia.

Hirschsprung's Disease-P. S. Potter, North Adams, Mass.

Unforeseen Death in Scarlet Fever-Drs. Gouget and Dechaux, Paris.

Radiographic Examination of the Gastrointestinal Tract from a Practical Standpoint; in connection with Diagnosis and Treatment of Gastroenteroptosis -H. K. Pancoast, Philadelphia.

Intracranial Complications of Acute and Chronic Superative Otitis Media-E. B. Dench, New York. Neuropathlogy in Childhood, with Consideration of Pathologic Factors in Some Cases of Retarded Mental Development-D. J. McCarthy, Philadelphia. Chronic Constitutional Headaches-T. Diller, Pittsburg.

Interstitial Keratitis-I. Lederman, Louisville, Ky. Exotic Dysentery-P. G. Woolley, Omaha.

The placing of Radiography in a special department is worthy of comment as this subject has now the position of a definite specialty.

This volume contains the annual number of excellent colored plates, illustrations and figures, and on the whole is well up to the standard.

Edward's Treatise on the Principles and Practice of Medicine.

A Treatise on the Principles and Practice of Medicine. By Arthur R. Edwards, M. D., Professor on the Principles and Practice of Medicine and Clinical Medicine in the Northwestern University Medical School, Chicago. New (second) edition thoroughly revised. Octavo, 1246 pages, with 100 engravings and 21 full-page plates in colors and monochrome. Cloth, $5.50 net; Leather, $6.50 net. Lea & Febiger, New York and Philadelphia, 1909.

Two years ago "Edward's Treatise on the Principles and Practice of Medicine" was given to the public, and in spite of the fact that there were a number of very excellent works, by American authors, with years of popularity behind them the new work was at once recognized as having a distinct place.

The appearance of a second edition which has been really revised attests to the determination on the part of both author and publisher to keep the place which has been won for the work.

The revision has been thorough, and we can not enumerate the points better than to quote from the preface:

"Particular attention has been given to reviewing therapeutic details in accordance with the recent awakening of the profession to the importance of logical treatment, numerous new preparations and modified names and doses, particularly for children, are explicitly specified. There are practically new chapters on the arrhythmias and other cardiac neuroses, tropical splenomegoly and various other tropical affections. Due consideration has been given to the meinigitis serum of Flexner, Jobling, Strong's work on Amebic dysentery, blood cultures in typhoid and other bacteriamias, the 'carriers of infection,' the recent epidemics of meiningitis and poliomyrtitis, the accumulating evidence in favor of spirochete as the cause of syphilis and the recent status of tuberculin in its various diagnostic uses as the ocular reaction and von Pirquets test."

The addition of new plates of diphtheria bacilli and Spirochete add materially to the illustrations.

As a text-book for students it can be especially recommended for it is clear concise and written in an entertaining style,

Looks, Pamphlets, Etc., Received.

From W. B. Saunders Co., Philadelphia, Pa.: Surgical Diagnosis, by Daniel N. Eisendrath, M. D. Second revised edition. Octavo of 855 pages, with 574 original illustrations, 25 in colors. Price, $6.50 net.

A Text-Book of Obstetrics, by Barton Cooke Hirst, M. D. Sixth revised edition. Octavo of 992 pages, with 847 illustrations, 43 in colors. Price, $5.00 net.

Medical Gynecology, by S. Wyllis Bandler, M. D. Second revised edition. Octavo of 702 pages, 150 illustrations. Price, $5.00 net.

Exercise in Education and Medicine by R. Tait McKenzie, A. B., M. D. Octavo of 406 pages, with 346 illustrations. Price, $3.50 net.

American Illustrated Medical Dictionary, by W. A. Newman Dorland, M. D., large octavo of 876 pages, with 2,000 new terms. Price, flexible leather, $4.50 net.

Text-Book of Modern Materia and Therapeutics, by A. A. Stevens, M. D. Fifth revised edition. Octavo of 675 pages. Price, $3.50 net.

Principles of Hygiene, by D. H. Bergey, M. D. Third revised edition. Octavo of 555 pages, illustrated. Price, $3.00 net.

Clinical Examination of the Urine and Urinary Diagnosis, by J. Bergen Ogden, M. D. Third revised edition. Octavo of 427 pages, illustrated. Price, $3.00 net.

Clinical Studies for Nurses, by Charlotte A. Aikens. 12 mo. of 510 pages, illustrated. Price, $2.00 net. From Treasury Department Public Health and Marine Hospital Service of the United States: Studies upon Leprosy. A Report upon the Treatment of Six Cases of Leprosy with Nastine (Deycke), by Walter R. Brinckerhoff, S. B., M. D., and James T. Wayson, M. D.

The Second International Conference on Leprosy, held in Bergen, Norway, August 16 to 19, 1909. By Donald H. Currie.

From Leartus Connor, A. B., M. D., Detroit, Mich. : Simple Refraction for Family Physicians, its Promotion During 1908-09. (Reprinted from the Journal of the American Medical Association, Oct. 9, 1909.)

The Rational System of Medical Education will furnish Physicians Adequate for the Entire Field of Medical Practice. (Reprinted from the American Academy of Medicine, October, 1909.) From Lea & Febiger, Philadelphia, Pa.:

Systemic Pathology, by George Adami, M. D., and Albert G. Nicholls, M. A., M. D., F. R. S. In one octavo volume of 1,082 pages, with 310 engravings and 15 colored plates. Price, $6.00 net.

From Thomas E. Satterthwaite, M. D., New York: Newer Conceptions of Cardiac Arrhythmias and Their Treatment. (Reprinted from the Medical Record, May 15, 1909.)

From William Seaman Bainbridge, A. M., Sc. D., M. D.:

The Enzyme Treatment for Cancer.

From S. L. Jepson, A. M., M. D., Wheeling, W. Va.: Rheumatism in Children. (Reprinted from the West Virginia Medical Journal.)

COMPLETE SERIES, VOL. LVIII, No. 12 NEW SERIES, VOL. III, No. 12

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Contributed Articles

A STUDY OF THE PARATHYROID GLANDULES IN TETANUS TRAUMATICUS.*

RALPH L. THOMPSON,

Professor of Pathology, St. Louis University School of Medicine.

(From Pathologisch-anatomisches Institut des stadt. Krankenhauses in Friedrichshain, Professor Dr. Ludwig Pick, Director.)

The severe symptoms of tetany that follow operative interference with the parathyroid glandules in animals, the details of which are now so well known, have from time to time led to the assumption that these organs were insufficient in certain diseases that manifested tetanic symptoms. In a few instances these assumptions have apparently been borne out by the finding of morphologic changes of im

portance in the parathyroids; for example, the presence of hemorrhage in the glandules of infants, found by Yanase, in cases of infantile tetany. In many cases, however, where a severe tetany manifested itself clinically, the parathyroid glandules have been found normal from a morphologic standpoint.

The author has recently reviewed the liter. ature very completely on these glandules, so that only such cases as bear on the present paper will here be referred to. In 1907, Guizzetti reported four cases of tetanus traumaticus in which he found certain changes in the parathyroid glandules, the most noticeable of which was lymphocytic infiltration, seen in two of the cases. Oedema of one parathyroid in one case, and hemorrhage residium in two parathyroids in another case was observed. One case showed no changes in the parathy roid glandules. During the present year Ba bonneix and Harvier have examined the para thyroids from three cases of traumatic teta nus, and in two of the cases have observed marked hypersecretion of colloid, which in places filled the smaller vessels as well as occurring within certain of the cells. These au thors also observed in one of the cases (an infant aged 31⁄2 years) a great number of "oxyphile" cells, although such cells are rare at that age. Marked congestion in one case

*Translation by the author from the Centralblatt fur Allgem. Pathol. u. Pathol. Anat., Bd. 20, No. 20, 1909.

also

and slight hemorrhage in another was noted. The third case observed by these au thors was of a chronic type, and less noticeable histologic alteration was seen than in the first two cases, in which death occurred forty. eight hours after onset of symptoms.

Through the kindness of Prof. L. Pick, I have been able to study the parathyroid glandules from five individuals dying with tetanus trau maticus. In every case four parathyroids were found and examined. The interpretation of the histologic findings was based on the previous examination of several hundred routine cases (Thompson and Harris).

While individual glandules in this series of tetanus cases have shown certain changes that cannot be exactly described as normal, I have failed to find any specific lesion that could be considered a result of the tetanus infection, and none of the cases showed sufficient mor

phologic alteration to suggest any impairment

of function. The lymphocytic infiltration de scribed by Guizzetti was not seen in any of these cases. Neither was there found any ex cess of colloid in the capillaries and in cells as found by Babonneix and Harvier, although in two of the glandules small colloid cysts occurred, as are not uncommonly found in parathyroids possessing the alveolar type of structure. In no case was there observed any increase of "oxyphile" cells or signs of hyper activity. A detailed description of the cases is as follows:

Johann W., aged 38 years. Death on third day of tetany. Autopsy findings unimportant except acute splenic tumor with great en largement of the follicles. Four parathyroid glandules found in normal situation. The left lower is the largest (10x5x3 mm.), the others average 6 mm. in longest diameter. They are dark red in color. Microscopically the glan. dules show marked congestion, including not only the larger vessels, but even the smallest capillaries, which are widely distended and filled with red-blood corpuscles. The "oxy phile" cells are few in number. There is mod erate fatty infiltration of all the glandules. One glandule shows a tiny colloid cyst, and another glandule shows near its center an acinous arrangement composed of ten or twelve small acini which contain colloid, such as may be found not infrequently in glandules which conform to this type of structure. In general

the parenchyma of the glandules appears normal.

Julius T., aged 48 years. Death on tenth day of tetany. Autopsy showed petechiæ su bendocardiale, hyperemia pulmonum, bronchi tis, tracheitis, nephritis parenchymatosa, gastritis et enteritis. Four parathyroid glandules found in normal situation. Average measurement 6x5 mm. Color, dark red. Microscopic ally, the glandules are all of the compact type, and present nothing worthy of note except marked congestion. The "oxyphile" cells are few in number. There is very little fat in the glandules, and no colloid.

Bertha L., aged 42 years. Clinical history Clinical history not obtained. Anatomical diagnoses. Infiltratio adiposa cordis. Hyperemia, oedema et emphysema pulmonum. Bronchopneumonia incip iens (lobi infer. dextra). Nephritis parenchy matosa. Tumor hepatis. Hyperemia meningum et cerebri. Four parathyroid glandules found in normal situation. The two superior glandules measure 10x3 mm; the inferior are so fatty that they cannot be exactly measured. Color extremely yellow. Microscopically, there is a periparathyroiditis about the right upper glandule between the thyroid and parathy roid, consisting of connective tissue formation which binds together the two structures. One of the superior glandules shows in its center the acinous arrangement with colloid-filled spaces as described in the first case. There is no increase of "oxyphile" cells, and only mod erate congestion, which is limited to the larger vessels. All four glandules show a consider able amount of fine intracellular fat, and the lower glandules especially show great fatty

infiltration.

Richard W., aged 19 years. Death on third day of tetany. Anatomical diagnoses. Hyperemia et ædema pulmonum. Hemorrhagica circumscripta subpleuralis et subepicardite. Enteritis. Nephritis parenchymatosa levis. Hyperemia cerebri. Four parathyroid glandules found, average measurement 8 mm. in longest diameter. The right superior and inferior lie close together on the posterior bor der of the lower third of the thyroid; the left are in normal situation. Color, dark red. Microscopically the glandules are of the compact type. They show only a few "oxyphile" cells and a moderate amount of fat. No colloid seen. There is marked congestion of all

the blood vessels.

normal size and in the usual situation. On the left side two bodies are found corresponding in their situation to the usual sites of the superior and inferior parathyroids respectively. They are not to be differentiated macroscopically from parathyroids except that they are of considerably larger size. The upper measures 15x8x2 mm. in diameter; the lower, 13x10x3 mm. Microscopically the glandules on the right side are of the compact type and are normal except for moderate congestion. The bodies on the left side are found microscopically to be remnants of thymus gland. Attached to the lower internal surface of the superior, however, and partly included in the thymus tissue, a parathyroid gland is found. Further search also shows the fourth parathyroid a little below and external to the inferior thymus body. Neither of these glandules present any changes worthy of note. They are moderately congested and show small amount of fat. No "oxyphile" cells are found in any of the glandules; neither is colloid present.

a

In conclusion, it may be stated that we have here a fairly complete series of cases of tetanus traumaticus ranging from very acute to moderately chronic in their course, and in young individuals as well as those of more advanced age. In every case all four parathyroid glandules have been found, and none have shown any constant change, or, in fact, any change, that might not be found in an examination of the parathyroid glandules from individuals dying with acute disease without tetany. The marked congestion found in practically all the cases is to be expected as a part of the general hyperemia occurring throughout the other organs in this condition. The lack of lymphocytic infiltration, and lack of colloid increase in this series, shows that such conditions are not necessarily specific for trau matic tetanus, and, indeed, we doubt if any pathologic alteration constantly occurs in the parathyroid glandules in this disease that may not be met with in an individual dying from any acute severe infection without tetany.

GONORRHEA IN THE MALE, AND ITS TREATMENT FROM THE VIEWPOINT OF THE PRESENT.

By HENRY J. SCHERCK, M. D. Consulting Genitourinary Surgeon, Missouri Pacific Hospital, Chief Department Genitourinary Diseases Jewish Hospital Dispensary.

Few diseases exist about which there has been so much written and about which exists such a multiplicity of remedies as gonorrhea,

way of treatment which shall insure definite results. Very many cases are over-treated, and infection is spread by too zealous procedures. Definite conclusions must be deducted as to the most efficient method of handling the disease a disease of grave importance, the results of which often extend over years of suf fering; the complications of which shorten life, and last, but not least, the pathological conditions which it may induce in the innocent partner of life, as has been so clearly proven by the writings of Lawson Tait, Wertheim, and others.

True gonorrhea is primarily a local infec. tion due to the deposit on a mucous membrane of the gonococci of Neisser. The primary object in the treatment is to destroy the activity of these germs as quickly as possible. The treatment of acute gonorrhea involving only the pendulous urethra is not a difficult task, but it is in the extension of the disease to the posterior urethra, seminal vesicles, the prostate gland, and even to portions of the bladder, that we meet with most obstacles. A careful study of the anatomy of the urethra and its contiguous structures is absolutely necessary to a proper and scientific understanding of the treatment of this disease.

I will not burden the reader with an exhaustive description of the anatomy of the genital apparatus, but will simply call attention to the more important points bearing directly on the treatment of this disease. We know that the urethra is lined with mucous membrane from the meatus to the bladder, and in the anterior urethra, which embraces the canal from the meatus to the triangular ligament, we have three kinds of glands opening into the canal-Cowper's glands, the crypts of Morgagni, and the follicles of Littre. All these glands belong to the class known as the com pound racemose variety. Littre's and Morgagni's glands resemble each other closely; Lit tre's, however, are much more numerous and are located mostly on the floor of the urethra. Cowper's glands are situated behind the anterior layer of the triangular ligament, their ducts opening into the bulbous urethra.

In the prostatic part of the urethra numer. ous glands exist. By careful examination the ducts are seen opening into the urethra from and around the region of the prostate. These openings are small tubes lined with epithelium, running into the substance of the prostate. The prostate gland itself contains a large quantity of unstriped muscular fibers running in various directions, and by means of the con traction of these the prostatic fluid is thrown into the urethral canal. Attention is espe cially called to this fact for the reason that in

cases of prostatic gonorrhea, where foci of infection remain imbedded in the gland, the infected pus is by means of this contraction thrown into the urethral canal, thereby reinfecting it. On either side of the sinus pocularis are the ejaculatory ducts, which convey the semen from the seminal vesicles. Beyond the verumontanum we have the prostatic tu bules, already referred to; their number varies greatly in different individuals. Careful at tention is called to these, as we often find them the seat of chronic inflammation, causing the adjacent structures to become hypertrophied, probably giving rise to probably giving rise to what is sometimes called enlargement of the third lobe of the prostate. In this region, also, we find the sphincter muscles dividing the anterior from the posterior urethra, the dividing line fre quently between the infected and the non infected portions of the urethra. I have called attention to these points of the anatomy as directly bearing on the scientific treatment of urethritis.

When the urethra has been infected with gonorrheal pus, pus, infection beginning at the meatus travels toward the sphincter muscle, and in uncomplicated cases is usually limited by this obstruction. If proper local treatment is begun, with careful attention to the mode of life and diet, together with certain internal medication, cases usually respond to treatment and promptly get well. In these cases infection is not deep, nor is it in truth more than a surface inflammation.

The observations herein recorded are the composite result of the study of many pa tients. The statements consist of the general deductions drawn from the results of the treatment employed.

When a patient comes to me, I get from him as complete a history as possible, with special reference to the length of time since the attack began; secondly, I ascertain whether the posterior canal or other structures posterior to the cut-off muscles are involved or not; thirdly, whether the present is the first attack or not. A microscopical examination is also made to discover the presence and conditions of the gonococci. From this history and examination I endeavor to establish whether it is an acute attack. As will be shown later, many patients come, thinking their cases are acute infections, but investigation shows them to be old infections made active by excessive sexual indulgence or the abuse of alcohol. In these cases we shall find, on examining closely with the endoscope, that at some point the infection has been lying dormant in some of the folds, crypts, or tubules of the urethral canal, and has been stimulated into fresh activity, thereby re

infecting the canal. It is from these patients that we often hear the remark, "I catch gonorrhea every time I attempt intercourse."

These cases, I repeat, are simply uncured cases, which, under certain conditions of congestion, irritation, and stimulation, become acute again and reinfect the healthy portions of the canal. If a patient presents himself with a history of recent exposure; free, purulent discharge, and red, angry mucous mem brane near the meatus, the probability is that it is an acute attack. A microscopical examination is made and the quantity of gonococci in the discharge is noted. The general form of treatment in such acute cases consists of the following procedures: The urethra is first carefully washed with lukewarm water, after which one of the more modern of the various gonococcicides is used, such as argyrol, protargol, or silver nitrate solution. All these drugs when used should be in solution of definite strength, and the solutions should be freshly prepared; the above mentioned may be dissolved in water. The following table shows the strength in which the various agents are usually employed by me:

Argyrol......5 to 10% solution
Protargol
.5% solution
Silver
.1/10% solution

Argyrol and protargol are salts of silver having strongly antiseptic and germicidal action, without so great an irritating effect as the nitrate.

Whichever solution is used should be introduced gently into the canal with a half-ounce hard-rubber blunt-pointed syringe until the anterior canal is distended. The solution is held there for five minutes, the patient closing the meatus by pressure of the fingers. Care should be taken not to force this solution beyond the cut-off muscle. In place of an aqueous solution of these drugs I am now employ,

ing them suspended in a jelly, composed of Iceland moss with 5% boric acid and 10% glycerine, which has an advantage, since it allows the antiseptic action of the drug to continue its effect by remaining longer in contact with the mucous membrane. This treatment should be practiced twice a day, and be kept up until the acute symptoms rave passed, which usually takes from six to seven days. After the acute inflammatory condition has subsided and the discharge assumes a muco-purulent character, irrigations should be begun in connection with the foregoing, which is carried out as follows: A two-gallon irrigator, filled with a 1-2000 solution of permanganate potassium, at a temperature of 120° F., is irrigated into the canal. The irrigator is raised to a height sufficient to cause the pressure easily to dis

tend the canal, yet not to overcome the sphincter muscle. As the canal is distended, the permanganate solution is allowed to escape and refill until the whole quantity of solution has been used. The nozzle employed is blunt-pointed, so as not to cause any injury to the delicate mucous membrane, and behind and around there is a cup-shaped guard to prevent the operator being soiled by the return flow. This guard is made of rubber and fits over the glass nozzle. From day to day the strength of the permanganate solution is increased gradually until about one in five hundred (1:500) is attained. Every second day a microscopic examination should be made of the discharge, and the decrease in the amount of the gonococci should be noted. In the series of cases of which I have kept notes, the average time required for complete destruction of the gonococci was from ten to fourteen days. When the discharge contains no more cocci the use of the silver solutions is discontinued and the permanganate solution is used alone, increasing it in strength as indicated by the condition of the case. This combined treatment, in the beginning, is practiced twice a day, if possible (if not, once a day will answer), and contained until the disappearance of the germs. Then only should injections of an astringent character be allowed and used by the patient. The average time required to cure these cases was three weeks; some required four or five weeks.

With reference to internal medication, the prime object is to cause the urine to become non-irritating, which is accomplished by dilu tion and alkalization; secondly, to make it aseptic and germicidal. The first object is attained by the administration of alkaline salts and the free use of dilutents, such as lithia waters, and the administration of diuretics, Triticum repens, saw palmetto and santal oil, while the urine can be made both sterile and

antiseptic by the use of urotropin (ammonioformaldehyde), a very happy combination being the following:

B Urotropin, gr. v;

Ol. santal, m x.

Ft. capsul. mol. no. i. Disp. tales doses No.

ΧΧΧ.

Sig: One capsule every four hours.

My observation is that the administration of urotropin as above causes the exhibition in the slightly acid urine of sufficient formaldehyde to make that excretion both germicidal and uri-solvent. It also favors the solubility of phosphates and oxalates, the precipitates of which, like that of the urates, are frequently a source of irritation. It is my practice to maintain this internal medication throughout the treatment, as it serves to reduce the inflam